Efforts to halt the spread of drug-resistant malaria in Myanmar have delivered encouraging results through the private health sector, but health experts warn the disease cannot be won outside the public health system - and that the country is still a potential “gateway” for the spread of drug resistance.
“Myanmar is now an important frontier to contain artemisinin-resistant malaria from spreading to other parts of the world. This is for two reasons: the past history of [indoor residual spraying with the insecticide] DDT and [anti-malaria drug] Chloroquine resistance tells the same route of spreading to Africa, and because it is an essential strategic area, especially in border areas with migrant populations,” deputy director at Myanmar’s Department of Health (DOH), Thaung Hlaing, told IRIN.
Pockets of resistance were discovered in Myanmar in recent years and include southeastern Tanntharyi Region near the Thai-Myanmar border, neighbouring Kayin State and the highlands of eastern Shan State.
Several plasmodium parasites cause malaria, the most serious being plasmodium falciparum, which is responsible for most deaths worldwide caused by malaria. This parasite subset has in recent years increasingly become resistant to the most effective form of known treatment, a combination of drugs known as artemisinin, said Chris White, the senior malaria technical adviser for the Asia-Pacific for Population Services International (PSI), which treats some 250,000 people in Myanmar for malaria annually.
Parasites that are resistant to anti-malarial drugs are more likely to result in severe illness and death, as common drugs do not work to control them.
“Migration is one of the big challenges in controlling drug-resistant malaria, both in terms of internal migration from one malaria-endemic township to another or to a state or region where malaria is not endemic - or migration [from] outside Myanmar where there is also drug-resistant malaria,” said Adelaida Degregorio, Save the Children’s deputy programme director in Myanmar.
Myanmar is “under the global spotlight” with efforts increasing to prevent the drug-resistant malaria spreading to India, Bangladesh, and eventually, sub-Saharan Africa, said White, who described Myanmar as a “gateway.”
“The reason why there was a growing population of resistant [plasmodium falciparum] parasites over time relative to other parasites [that cause malaria] is because they increase in number as weaker parasites diminish,” he said, calling it a “survival of the fittest”.
As a result of extremely low spending on public health during half a century of military rule, some 80 percent of health services are provided through the private sector, according to a report published in 2013 by the London School of Tropical Hygiene and Tropical Medicine.
In 2000, the World Health Report ranked the country 190 out of 191 member states on overall health system performance. During the following decade prior to the current government’s election to power in 2011, social service investment continuously shrank until the public health sector was only 10 percent of the health system (which has since gone up somewhat), according to a November 2013 report on rehabilitating health in the Myanmar transition from the US think tank, Centre for Strategic & International Studies (CSIS).
As a result, anti-malaria medications are typically obtained from untrained vendors at privately-operated village kiosks.
“The private sector largely sells what it knows it can sell - and what it can sell is often driven by poverty. In a typical interaction, a provider doesn’t say ‘Tell me your symptoms.’ Instead they ask, ‘How much money do you have?’” White said.
He added that many rural communities can only afford a partial course of medication, which increases resistance because the parasite is more likely to survive in the bloodstream.
Studies have also found that the markets have historically been flooded with low-quality, mono-therapy anti-malaria drugs, as well as counterfeit medications, according to the representative of the Malaria Consortium in Myanmar, Yasmin Padamsee Forbes.
A key driver of malaria resisting treatment in Myanmar was the widespread availability of oral artemisinin monotherapy (AMT), as opposed to combination therapies that decrease the chance that mosquitoes can genetically mutate and dodge treatment.
“If you keep bombarding the parasite with one ingredient the probability of genetic mutation increases,” said White.
In mid-2012, PSI signed a contract with AA Medical, which has an 80 percent market share of anti-malarial medication in Myanmar. Now AA Medical only sells combination therapies supplied by PSI. Myanmar’s Ministry of Health has since banned importation of AMTs.
Although combination therapies are far more costly than mono-therapies, donor subsidies have reduced the cost for a full course of the combination therapies to 50 US cents - the same price as a partial course of the most widely available mono-therapies. The medication is made in India, but repackaged in Myanmar to include picture descriptions of how to administer the drug day and night, and co-formulated to ensure both components are taken.
An audit conducted by PSI in June 2013 at 3,500 kiosks in the priority resistance containment region of eastern Myanmar found that the volume of combination therapy sold there, relative to monotherapy, increased from 3 percent in mid-2012 to 73 percent in mid-2013.
However, the battle against drug-resistant malaria will not be won unless the public sector is involved, said David Bell, a malaria diagnostics expert, public health physician and scientist at the Seattle-based Intellectual Ventures Laboratory. The private-sector initiative funded by the US philanthropist Bill Gates is pursuing inventions that can be adapted for low-resource settings, such as optical TB and malaria diagnostics, an improved milk transportation system and passive vaccine storage.
“The private sector makes money by selling drugs, rather than through diagnosis... or through follow-up,” added Bell.
He said public health workers can train private health vendors to carry out blood tests for malaria, citing Senegal and Zambia as successful case studies.
"If remote people with limited health training can successfully perform malaria diagnosis with RDTs [rapid diagnostic tests], private sector vendors with similar backgrounds can also. Good diagnosis can be done remotely now, so there is no technical reason why remote private vendors cannot do it. "
However, he noted that getting trained health professionals into remote areas to collaborate with private sector health workers requires both sides to work with each other in new ways -- and good management.
Most areas where drug-resistant malaria has been lab-confirmed in Myanmar are remote, with little access to public health services, and/or have transient populations in border areas.
Bell suggested donors support schemes that provide the private sector with financial incentives for good disease management, along with training in diagnostics and treatment adherence follow-up.
But most donors’ health funds still flow through agencies and international NGOs, and “how Myanmar will move beyond the parallel [health] system remains unclear,” noted CSIS.
"Everyone acknowledges the need to scale up good quality public services, to ensure patients receive care from qualified providers and to ensure price isn't a barrier to access,” said White.
“However, this will take time. In the context of an emergency response to drug resistance, one must recognize that the pervasive and dominant private sector is a serious threat if ignored, but a powerful ally if utilized, even if only in the short term.”